Several posttraumatic stress disorder (PTSD) treatments1,2 have demonstrated efficacy across various trauma-exposed samples,3 including veterans.4 Only half of veterans with PTSD seek treatment5 and not all respond to treatment.6 These findings highlight needs to explore other treatment options for PTSD. Mindfulness-based approaches are being explored as treatments for PTSD.7,8 Mindfulness programs are designed to teach individuals how to attend to the present moment and accept their own experiences.9,10
One mindfulness-based intervention is the Mantram Repetition Program (MRP) (Table 1). A mantram (spelling reflects method by Easwaran11) is a sacred word or phrase (eg, Ave Maria; Shalom) that is silently repeated for cultivating mindfulness. Mantram repetition does not require quiet surroundings, specific posture, designated time of day, or any particular beliefs. Therefore, MRP is convenient, transportable, and implemented without changing one’s environment or activities. Research on MRP effects has demonstrated reduced perceived stress, anxiety, and anger, and improved quality of life and spiritual well-being.12–15 Furthermore, a randomized controlled trial demonstrated that veterans with PTSD who received MRP combined with treatment as usual (MRP+TAU) significantly reduced PTSD symptoms compared with those who received TAU alone.16
Mindfulness-based interventions, including MRP, have demonstrated efficacy in treating various psychological symptoms, but it is important to explore how these interventions work.17 Mindful attention may be 1 mechanism that promotes improvements. Theoretically, for mindful attention to be an agent of change, (1) it must improve after mindfulness-based interventions, (2) improvements must mediate outcomes, and (3) heightened mindful attention should accompany more MRP practice.
Research on mindfulness as an outcome of mindfulness-based interventions has reported improvements among diverse samples. Several mindfulness studies have utilized the Mindful Attention Awareness Scale (MAAS)18 and reported significant increases in self-reported mindful attention.19–22 Improvements have also been shown using the Five Facet Mindfulness Questionnaire (FFMQ).9,23,24 Although the MAAS and the FFMQ measure self-reported mindfulness differently and highlight diversity in assessing the construct, both instruments illustrate change following mindfulness-based interventions.
Increased mindful attention, measured with MAAS, has mediated improvements in numerous psychological outcomes. For example, increased mindful attention was associated with decreased anxiety, stress, and rumination, along with increased self-compassion among participants receiving Mindfulness-based Stress Reduction (MBSR).18,21 In a study comparing MBSR, Easwaran’s Eight-Point Program, and a waitlist control, participants in both mindfulness-based programs increased in mindful attention, mediating reductions in rumination and perceived stress.22 In sum, these mindfulness-based interventions increased self-reported mindfulness, which in turn affected psychological well-being.21,22
Validation research has documented relations between mindful practices and subsequent growth in mindful attention. One study showed that time spent practicing mindfulness was associated with improvement in mindful facets (all except Describing) using FFMQ, symptom measures, and well-being.23 Mindfulness fully mediated the relationship of mindfulness practice with psychological symptoms and perceived stress; partial mediation was noted between mindfulness practice and well-being. Another study reported that mantram practice frequency (tracked by wrist counters) was inversely associated with intrusive thoughts, anxiety, and depression, and positively associated with quality of life and existential spiritual well-being.15
The current study extends previous findings16 by addressing 3 questions: (1) Does mindful attention (using MAAS) increase among veterans with PTSD following the MRP+TAU condition? (2) Do increases in mindful attention mediate changes in outcomes? (3) Is mantram practice frequency associated with increased mindful attention? We expected that veterans in the MRP+TAU condition, compared with TAU alone, would demonstrate significant improvements in mindful attention. Similar to previous findings,15,25 we hypothesized that increased mindful attention would mediate improvement in outcomes. Finally, we hypothesized that mantram practice frequency would serve as a mediator between the intervention and mindful attention, taking into account pretreatment mindful attention.
The sample included 146 veterans with military trauma (excluding military sexual trauma; MST) who sought outpatient care at PTSD clinics. Participants were at least 18 years old and met diagnostic PTSD criteria based on military trauma. Participants were randomly assigned to 1 of 2 conditions, MRP+TAU and TAU. For additional demographics, methods, and treatment descriptions, please refer previous work by Bormann et al.16
The Clinician Administered PTSD Scale (CAPS)26 is a structured clinical interview for the assessment of PTSD and the version utilized for the current study corresponded to the DSM-IV-TR symptom criteria.27 The CAPS was used to determine study eligibility and a total severity score to evaluate symptom change.
The PTSD Checklist28 is a 17-item, self-administered instrument used to assess self-reported PTSD severity. Each item corresponds to DSM-IV-TR symptom criteria. Cronbach α in the current study was α=0.89.
The Brief Symptom Inventory-1829 is a self-administered questionnaire with subscales reflecting depressive symptoms, anxiety symptoms, and somatization. We used the 6-item scale for depression (internal reliability α=0.97).
The norm-based Mental Health Component Summary from the Health Survey Short Form-12, version 2 (SF-12v2)30 was utilized for overall psychological well-being. The SF-12v2 was developed as a brief version of the SF-36 and has been shown to be valid in samples from the United States and Europe.
The Mindfulness Attention Awareness Scale (MAAS)18 is a 15-item self-report measure of a core component of mindfulness, particularly, awareness of present experiences. Internal consistency for the MAAS was α=0.89.
Mantram practice was assessed using a wrist-worn counter (golf scorer) and daily-tracking log. This method was used not to capture each single repetition, but rather, the number of occasions (sets) per day that a participant repeated a mantram at least once. These data were collected over the last 28 days of the MRP and this method is consistent with measurement in previous studies (for fuller description).15,31 For each MRP participant, 28 days of mantram practice data were collapsed to yield a single measure, the average number of daily mantram sets.
Data Analysis Plan
Treatment effects were analyzed using hierarchical linear modeling (HLM). Intent-to-treat analysis was conducted on 146 participants using multiple imputation (MI) to adjust for missing data. MI-based estimates were derived from m=50 distinct imputation sets, using MI routines in Stata13.32 Missing value imputations used the multivariate normal method with pretreatment and posttreatment measures treated as separate variables (potentially correlated, allowing for within-person consistency) and treatment group, age, and sex were predictors. HLM models included a subject-level random effect, and fixed effects for time point, treatment group, their interaction, and for any variable tested for mediation. Analyses of whether MAAS mediated outcome variables were conducted in HLM using procedures from Baron and Kenny.33
Only 4 of 71 MRP participants (6%) failed to report any mantram practice and 3 of 4 lacked complete MAAS data. These were treated as missing values. The remaining 67 participants reported mantram practice data on an average of 26.2 (94%) days of 28 possible. For these participants, a summary variable of the average number of mantram sets per day was calculated in 2 ways: (1) the mean of each individual’s nonmissing daily reports; and (2) the mean of 28 daily values, replacing missing values with HLM estimates from regressing all daily practice data on indicators for week (3–6), day of the week (1–7), and a random subject effect. These 2 averages correlated very strongly (r=0.99) among the 67 MRP participants; therefore, subsequent analyses used the imputed values.
In HLM analyses of treatment effects, the mantram practice variable, mindful attention, and psychological well-being were conceptualized as varying over time. Mantram practice was conceptualized as an individual’s average number of mantram sets reported since the beginning of MRP. At pretreatment, all values were assigned as zero. At posttreatment, TAU group participants’ values were still zero, but MRP participants were assigned the average of 28 reported (or imputed) number of daily mantram sets.
Of those randomly assigned to condition, 4 (2 from each condition) dropped before pretreatment assessments and 6 (3 from each condition) dropped before completing treatment. These 10 did not significantly differ on demographic or outcome variables from those who completed assessments.16
Medical record review revealed that TAU content did not differ between conditions. Medications changed for 20 and 16 participants in the MRP+TAU and TAU conditions, respectively (t=0.96, ns). There were 21 and 28 case management visits in the MRP+TAU and TAU conditions, respectively (t=−1.01, ns).16
Treatment Effect on Mindful Attention
Treatment effects were estimated in HLM models as MRP+TAU pre-post group change minus the TAU pre-post group change. The treatment effect was 6.46 MAAS scale units (P=0.0006, 2-tailed, N=146) with a standardized effect size of d=0.50. Figure 1 shows MAAS changes in treatment and control groups from pretreatment (week 1) to posttreatment (week 6).
Mediation of Well-Being Outcomes
Mediation analyses showed mindful attention mediated the effects of MRP on both PTSD symptom measures, depression, and psychological well-being measures. Table 2 documents with intent-to-treat analyses, all criteria for full mediation were met with statistical significance.33
Mediation of Mindful Gains by Mantram Repetition Practice Sets
The 66 responding MRP participants averaged 7.97 (SD=6.32) mantram practice sets per day; the 65 with complete MAAS data averaged 7.80 (SD=6.25). Figure 2 shows that this measure of mantram practice statistically mediated the effect of MRP on mindful attention (P=0.04 for Sobel test for indirect effect).33 In particular, Figure 2 (estimate B2) indicates that each daily mantram set was associated with an increase in the experienced MRP effect on mindful attention of 0.029 pretreatment SDs (ie, a 0.029 increase in d); thus, 15 mantram sets per day could be associated with a gain in mindful attention of approximately d=0.44, and 25 sets could be associated with a predicted gain of d=0.73.
This study explored changes in mindful attention after participation in a MRP+TAU intervention for veterans with military-related PTSD. Participants in MRP+TAU condition showed greater increases in mindful attention compared with those who received TAU alone. This study also demonstrated that increases in mantram practice frequency mediated improvements in mindful attention. Mediation by mindful attention supports 1 hypothesized mechanism of how MRP works to improve PTSD symptoms, and complements prior evidence that existential spiritual well-being partially mediates reductions in PTSD symptom severity.34 Different mediators may reflect different facets of the array of psychological changes theorized to occur through interventions such as MRP.11,14,35
There were several strengths of this study. The intervention is a novel, portable treatment for PTSD. The study used a randomized controlled trial design, which is the most stringent method for evaluating treatment outcome. Psychometrically sound assessment instruments, including CAPS, were used for assessing PTSD. Dropout was particularly low suggesting that MRP+TAU and TAU were well received and tolerated by veterans. Findings showed no significant differences between conditions on medication changes or number of provider visits, suggesting that outcomes were not a result of these factors. Finally, and notably, mindful attention improvements were observed following the 6-week MRP, demonstrating the efficacy of the intervention.
There were also limitations. The control group did not meet weekly during the 6-week intervention period. Therefore, some results might be attributed to the nonspecific effects of social support. Measurement of mindful attention relied only on the MAAS, which raises consideration whether mindful attention can be depicted by a brief self-report measure and, if so, which measure is best?36 The method for tracking mantram practice did not include length of practice sets, which may influence outcomes. Veterans self-selected knowing that the study involved “mantram repetition.” Findings cannot be generalized to veterans who have experienced other trauma (ie, sexual trauma, MST, nonmilitary trauma), have active substance use, or to female veterans, as the majority of participants were male.
In summary, the 6-week MRP was well received and demonstrated significant increases in mindful attention when delivered as an adjunct to usual care. This is important based on evidence that increased mindful attention further mediates improvements in psychological well-being. In addition, mantram practice frequency mediated the relationship between MRP and mindfulness. Together, findings suggest that mindful attention is 1 mechanism for change in psychological outcomes following the MRP+TAU. Future research investigating mindful attention as both a mechanism and outcome is needed in populations not yet studied, such as female veterans, active duty military, and individuals with varying trauma. Complementary, mindfulness-based therapies such as the MRP may be a welcome adjunct, and possibly alternative, to current PTSD treatments.
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